Eating disorders (EDs) are ordinarily thought of as affecting teenage girls and young women. However, in the past five years, ED patients of all ages and both sexes have been presenting more often for treatment (Andersen, Cohn, & Holbrook, 2000; Hegybeli, Cumella, & Wandler, 2004; Zerbe, 2003). The ED literature is beginning to offer data and clinical observations on EDs among the elderly, women in midlife, males, and pre-adolescent children.

Clinical experience suggests that the primary causes, features, and treatment needs of ED patients are similar across the lifespan and for both sexes (Andersen, 1995; Robert-McComb, 2001). As such, any practitioner who works with ED patients in these newly-identified groups can practice competently beginning with a sound overall knowledge of EDs. Useful guides to general ED assessment, conceptualization, and treatment are Eating Disorders and Obesity: A Comprehensive Handbook by Fairburn and Brownell (2002); Eating Disorders: A Clinical Guide to Counseling and Treatment by Woolsey (2002); and Body Image, Eating Disorders, and Obesity in Youth by Thompson and Smolak (2001). Many other useful guides exist.

As most practitioners will recognize, the standard of care for all ED patients involves the following elements (American Psychiatric Association, 2000):
• multi-disciplinary assessment
• weight restoration and normalization of androgen levels
• reduction in destructive behaviors, including bingeing, purging, and excessive exercise
• helping patients to change distorted cognitions about weight and shape
• addressing co-occurring disorders and issues; most commonly depression, anxiety, substance use,
trauma, and Axis II features
• preparing patients for discharge and follow-up

However, important differences in etiology and treatment needs do exist for the newly-identified ED populations. This article explores those unique issues for each of the emerging ED populations.

The elderly
Elderly men and women may exhibit EDs more often than most clinicians realize (Hewitt, Coren, & Steel, 2001). Because few have thought to screen for EDs in the elderly, many of these cases have been overlooked, with tragic consequences. Research suggests that most deaths (78 percent) from anorexia nervosa occur in persons over the age of 65 (Hewitt, Coren, & Steel, 2001). Anorexia nervosa is a very serious illness in seniors because many already have compromised health.

Some elderly persons living on their own are limited in their contact with others. Therefore, eating disorders may go unnoticed. For those in restricted situations, such as nursing care centers or assisted living facilities, it is not uncommon to refuse food and become dangerously thin (Miller et. al., 1991). Typical excuses — “I’m full,” “I feel sick,” “I have no appetite,” — are often accepted at face value, but should be challenged to determine whether there is a deeper issue.

ED origins among the elderly are surprisingly similar to etiological factors identified for young women, but with a unique stage-of-life dimension (Faulkner-Wiley, 2001). Refusing food is often an attempt to control the one domain the person still feels able to control — what is entering the mouth. For elderly persons living alone, limited food intake can simply be a response to being unable to afford groceries. In this situation, elderly persons may convince themselves that they do not require much food because they are inactive and because being thin is healthy.

Refusing food may also be a protest or communication aimed at loved ones; an expression of distress over activity restrictions or limited family visits. Even more serious, refusing food may be a passive effort to commit suicide arising from hopelessness, despair, and depression. In each of these situations, body image issues may or may not co-exist. When they do, often the elderly person blames their aging body for the unwanted changes in their life, and may experience body hatred as a result. In the absence of body image issues, the elderly person might still have an ED. Their diagnosis would be eating disorder not otherwise specified.

It is essential to evaluate why elderly persons are restricting their food intake. As we age, taste buds grow less sensitive and appetite decreases. Also, certain medicines can blunt taste and sense of smell, and many illnesses result in reduced appetite. Pain can make grocery shopping, cooking, and eating more difficult. These possibilities should be evaluated for elderly persons with eating problems. However, clinicians also should evaluate psychosocial underpinnings of eating problems in the elderly. This latter assessment is frequently overlooked because many assume that it is normal for elderly persons to be experiencing depression and hopelessness and to be refusing food. These symptoms, however, are pathological, and should be treated regardless of a person’s age (Hsu & Zimmer, 1988).

Eating disorders in elderly persons are treated with cognitive-behavioral and interpersonal psychotherapy, psychiatric medications, and nutrition education and support (Clark et al., 1999). Because of the medical issues that may be complicating and sustaining eating disorders in the elderly, programs to provide healthy meals, physical rehabilitation, disability-related environmental modifications, and appetite-stimulating medications may also be useful.

Women in midlife
In the past five years, ED clinics and inpatient treatment centers have seen a continual rise in midlife patients seeking treatment (Morris, 2004). Remuda Ranch Programs for Anorexia and Bulimia, the nation’s largest inpatient facility for ED, has experienced a 400 percent rise during the past decade in patients over 40 years old. Traditional wisdom among ED specialists once suggested that EDs do not occur after age 35, but a growth in midlife cases has supplanted this wisdom (Zerbe, 2004). However, many healthcare professionals have not heard about midlife ED. Therefore, screening and identification of midlife ED patients may not be occurring on a regular basis (Zerbe, 2004).

EDs arise, re-appear, or worsen during midlife usually following life transitions (Bellafante, 2003). Typical transitions that may lead to ED behaviors include:
• Parent’s Illness or Death — Some women may fear independence or feel ill-equipped to manage the demands of adulthood. EDs often lead to physical debility, such that others rally around the woman and enable her to maintain a dependent role.
• Sibling/Peer Deaths — These events lead people to confront their mortality. Women may defend against this by seeking youth through extreme dieting and exercise.
• Divorce/Separation — Raises issues of dependency, fears of being alone, low self-esteem in the face of not having a partner and possibly having to “market” oneself by dating again. This can intensify focus on appearance and lead to excessive measures to lose weight or achieve an idealized body.
• Traumatic Illness — Illnesses such as breast cancer can deeply impair a woman’s body image and acceptance of her body. To compensate, a woman may resort to extreme measures to reshape her body or reclaim a youthful appearance.
• Evidence of Aging — Events such as graying hair, menopause, wrinkles, and midlife weight gain may be particularly difficult for some women to manage if their primary identity and self-esteem have come from appearance. They may fear loss of partners’ attention. A woman can have a midlife crisis and seek youth through unhealthy methods, such as ED behaviors.
• Child’s Death — May lead to despair and a desire to die. Self-starvation can be a form of indirect suicide and a plea for help in the midst of unbearable suffering.
• Remarriage — A woman may have trouble transitioning into a new family system if it differs from the one she has known, and may have difficulty expressing her needs or feelings. EDs garner the attention and notice of others and can be a voice for someone who does not know how to express herself in other ways.
• Empty Nest — For some women, their main identity is as a mother. When children leave home, these women may experience a crisis of meaning and value. Focusing on appearance, diets, health, and exercise can feel meaningful in the absence of other life pursuits and can also be a way of garnering attention from husbands or family members who, the women fear, may no longer need or even want them in their lives.

In midlife women with ED symptoms, good practice begins by evaluating possible medical etiology, since ED symptoms can resemble those of other of illnesses, including thyroid disease, malignancies, and diabetes (Zerbe, 2003). It is also important to remember that midlife women with EDs have often had a subclinical ED for a long time which has remained undiagnosed and untreated, such that substantial debilitating effects of prolonged semi-starvation and excessive exercise may be present.

Psychotherapy with these patients often includes several foci (Zerbe, 2004). First, it can be quite useful to help the woman to build a new identity based on her life successes and personality characteristics rather than her physical appearance. Second, it is often necessary to assist the woman in recognizing and processing her grief regarding the loss of her maternal role and youth. Third, because women in this situation often have learned to put others’ needs before their own, assertiveness training can be beneficial. Assertion is a powerful replacement for the indirect request for attention expressed through eating disorder symptoms.

Finally, there is often a spiritual component to treatment with midlife women, if a particular patient is open to this. Spirituality can help to promote a sense of transcendence and meaning in relation to maturity, allowing the woman to attain a new understanding of herself — her value as a mature person who has achieved significant goals and learned important life lessons.

Males
It is unclear whether or not EDs among males are increasing, although many authorities believe they are becoming more common. More importantly, it is believed that males with EDs have often gone unidentified and untreated. Therefore, as healthcare professionals become more aware of ED problems in males, more ED males will need treatment (Andersen, 2000).
As with females, adolescence is the typical onset time for males with ED. However, there appear to be three onset groups (Andersen, 1995; Andersen, 1999). Preadolescent males may develop ED in an effort to reduce obesity-related teasing from peers. Adolescent and young adult males may develop ED because of sexuality and sexual identity conflicts. Finally, adult males may develop ED in an effort to achieve a sense of masculinity and control in marital and work situations. Males from weight-sensitive sub-groups, such as actors, wrestlers, and gymnasts, are particularly at risk for developing EDs.

Although males with eating disorders resemble their female counterparts symptomologically in many ways, meaningful differences also pertain (Cumella, 2003). ED males frequently have histories of obesity, unlike women with eating disorders. Only ED males practice ED behaviors to become larger and more muscular, and more often they are motivated by a desire to improve athletic performance. ED males are more likely to have gender identity concerns and reduced or impaired sexual activity, but they report sexual abuse histories far less often. ED males have more extreme obsessions and tend to be more impulsive, with greater use of substances and excessive exercise and more antisocial personality features. ED males have often been emotionally or physically separated from their fathers. For ED males, the ED is often motivated by a desire to avoid weight-related illnesses that have been witnessed in male relatives. One manifestation of EDs occurs virtually only in males — “reverse anorexia,” also known as “muscle dysmorphia,” “bigorexia,” and “vigorexia.” In this condition, no amount of bigness/muscularity is sufficient. Unlike women, half of the men with EDs are displeased when their weight drops because they believe they are too small. ED males also are unhappy with their upper bodies wanting broader shoulders and forearms, while females focus on the lower body (Andersen, 1992).

Effective therapy for ED males is similar to treatment for females but, additionally, includes muscular development exercises and male-only therapy groups to focus on sexuality, social roles, emotional expression, and father-son relationships (Andersen, Cohn, & Holbrook, 2000). Nutritional interventions target weight increase until testosterone levels normalize.

Children
A 2002 survey of healthcare practitioners (National Association of Anorexia Nervosa and Related Disorders, 2002) suggests that anorexia nervosa is becoming more prevalent in children of both genders. It is still rare to see bulimia nervosa in pre-teen children — 63 percent of US teachers indicated in a survey that EDs are a problem in their schools. Between 50 and 75 percent of pre-teen girls are dieting; girls who diet prior to age 14 are eight times more likely to develop EDs (Cumella, 2004). Researchers believe that apparent increases in EDs among children are related to the declining age of menarche in U.S. females, and also to media that specifically target male and female children with messages promoting dieting and body image dissatisfaction.

Children with EDs are at great risk of medical complications (Ebeling et al., 2003; Hegybeli, Cumella, & Wandler, 2004). Complications and physiological decompensation occur rapidly in children, and if the ED occurs during a critical growth period, malnutrition could stunt the child’s growth forever. Aggressive medical treatment is therefore warranted.

Sometimes children fail to present with the full diagnostic criteria for anorexia and bulimia, but there may be a range of ED symptoms potentially diagnosed as eating disorder not otherwise specified. ED symptoms in children also may be intertwined with trauma-related pervasive refusal — refusal to talk, eat, drink, walk, etc. Children with EDs frequently have co-occurring obsessive-compulsive disorder, other anxiety disorders, and extreme self-esteem deficits. However, they are often less depressed than adolescents and adults with EDs (Gislason, 1988).

Therapy with ED children is most effective when it includes resiliency and self-esteem/identity work. Exposure with response prevention is frequently warranted to address severe obsessive-compulsive and anxiety symptoms related to ED behaviors. Family systems issues and dynamics are commonly at the heart of children’s ED behavior and such family problems will likely lead to relapse if not addressed. Family therapy is therefore an essential adjunct — and often the primary treatment — with ED children (Lask & Bryant-Waugh, 2000).

Clearly, eating disorders are appearing across the lifespan in males as well as females. It is critical for healthcare professionals to be aware of eating disorders in these emerging populations so that proper screening and treatment can occur to reduce the consequences of these potentially life-threatening illnesses.

Edward J. Cumella, Ph.D. is Director of Research and Education at Remuda Ranch Programs for Anorexia and Bulimia. He presents frequently at professional conferences, has written many peer-reviewed articles, and has been interviewed by local and national media as an eating disorder expert.

References
American Psychiatric Association (2000). Practice guideline for the treatment of patients With eating disorders (revision). American Journal of Psychiatry, 157(Suppl.), 1-39.
Andersen, A. (1992). Eating disorders in males: A special case? In Brownell, K., Rodin, J., & Wilmore, J. (Eds.) Eating, body weight and performance in athletics: Disorders of modern society. Baltimore: Williams & Wilkins.
Andersen, A. (1995). Eating disorders in males. In K.D. Brown & C.G. Fairburn (Eds.), Eating disorders and obesity: A comprehensive handbook. New York: Guilford Publications.
Andersen, A. (1999). Eating disorders in males: Critical questions. In R. Lemberg & L. Cohn (Eds.), Eating disorders: A reference sourcebook (pp. 73-79). Phoenix, AZ: Oryx Press.
Andersen, A.E., Cohn, L., & Holbrook, R. (2000). Making weight: Men’s conflicts with food, weight, shape, and appearance. Carlsbad, CA: Gurze Books.
Bellafante, G. (2003, March 9). When midlife seems just an empty plate. The New York Times, pp. 9-1, 9-4.
Cumella, E.J. (2003). Examining eating disorders in males. Behavioral Health Management, 23, 38-41.
Cumella, E.J. (2004). Children with eating disorders. Arizona School Boards Association Journal, 34, 22-23.
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Fairburn, C.G. & Brownell, K.D. (2002). Eating disorders and obesity: A comprehensive handbook. New York: The Guilford Press.
Faulkner-Wiley, I. (2001, June 7). Laura was killed by anorexia. She was 80. The Guardian, p. 16.
Gislason, I.L. (1988). Eating disorders in childhood. In B.J. Blinder, B.F. Chaitlin, & R.S. Goldstein (Eds.). The eating disorders: Medical and psychological bases of diagnosis and treatment. New York: PMA Publishing Corp.
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Lask, B. & Bryant-Waugh, R. (2000). Anorexia nervosa and related eating disorders in childhood and adolescence, 2nd ed. East Sussex: Psychology Press Ltd.
Morris, B.R. (2004, July 6). Older women, too, struggle with a dangerous secret. The New York Times, p. F-5.
National Association of Anorexia Nervosa and Related Disorders (2002). Who suffers from anorexia nervosa? Retrieved December 15, 2002, from www.anad.org.
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This article is published in Counselor,The Magazine for Addiction Professionals, August 2005, v.6, n.4, pp.41-46.

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